Mental Health Coaches Seek to Fill Gaps, But Oversight Lags
“I‘d rather just skip lunch today,” read a June text from Megan McArthur. The message was addressed to Cambria Camp, an eating disorder recovery coach McArthur had been working with since the previous December. McArthur said that, through a text exchange, Camp helped her remember that regular meals are crucial for eating disorder recovery and guided her through assembling a nutritious meal from the products in her kitchen.
After years of food struggles and multiple hospitalizations, McArthur might have found the missing piece in her treatment plan. The 38-year-old, who described being diagnosed with multiple eating disorders starting in 2018, says she had already been through multiple hospitalizations, residential stays, and outpatient programs. While she made progress in those settings, she said she would struggle to maintain recovery after returning home. The coaching, she told Undark in a recent interview, helps bridge these experiences with the real world: “Having a coach really helps me live my actual life and choose recovery instead of just leave my life, go into the recovery world, live in my recovery bubble, and then come back and try to intermingle the two.”
Many coaches offer services similar to Camp’s for eating disorder recovery. And some research suggests that coaching is becoming more popular for obsessive-compulsive disorder, or OCD, as well. Coaches use their own experience with mental illness to help their clients navigate day-to-day recovery challenges, though their exact approaches can vary widely. Peer support has been around for decades — Alcoholics Anonymous, for instance, has long relied on its more seasoned members to assist those starting recovery. The role became formalized starting in the 2000s in addiction recovery, with the emergence of recovery coaches, and soon spread to other disorders.
Proponents of mental health coaching say it can be more accessible than traditional treatment: Although rates vary and it is not covered by insurance, coaching may be cheaper than therapy and can be offered across state and national boundaries, including areas with limited access to specialized care. Coaches, proponents say, can also offer greater flexibility, providing support when and where clients need it, bridging the gap between formal therapy sessions. And coaches usually have personally experienced the conditions they address, which may make them more relatable than traditional providers.
“Having a coach really helps me live my actual life and choose recovery instead of just leave my life, go into the recovery world, live in my recovery bubble, and then come back and try to intermingle the two.”
Although coaching for eating disorders and OCD has drawn attention in recent years, it has also raised concerns. The profession has no clear legal definition and requires no licensing. “Pretty much anybody can put a shingle out and say they work with eating disorders,” said Cynthia Bulik, a clinical psychologist and founding director of the University of North Carolina Center of Excellence for Eating Disorders. She told Undark that she is also troubled about the lack of clinical trials showing the efficacy of coaching. “I want data,” she said. “I want data to see if this is helpful or harmful or neutral. I just don’t know.”
While some experts do see potential benefits in adding responsible coaches to treatment teams for eating disorders, the view on OCD coaching tends to be more critical. A few experts told Undark that in OCD, coaching might be ineffective at best and harmful at worst. And for both cases, the lack of regulations can make it easy for coaches to exploit vulnerable people by making promises that experts say are unrealistic. Coaches themselves admit that the field isn’t perfect. As Eric Pothen, an eating disorder recovery coach, put it, coaching “can be something really helpful and also, on the other hand, it could be very dangerous and harmful for individuals as well.”
Eating disorders are a diverse group of mental health conditions, characterized by significant distress and harmful patterns of behavior related to food, exercise, or weight. Though the spectrum is broad, common types include restrictive anorexia nervosa (persistent restriction of food intake and often significant weight loss), bulimia nervosa (episodes of binge eating followed by behaviors such as self-induced vomiting or excessive exercise), and binge eating disorder (repeated episodes of overeating typically accompanied by a sense of loss of control). Evidence-based treatment for eating disorders typically involves nutritional rehabilitation paired with psychotherapy, which aim to introduce healthier behaviors around food, exercise, and weight.
Consistent, real-world exposures to feared foods and situations — such as eating out at a restaurant — are critical to recovery, which is where coaching could help maintain momentum. In eating disorders “you need exposure to the feared thing,” said Carolyn Costin, a licensed marriage and family therapist who in 2017 opened the Carolyn Costin Institute, or CCI, which offers an online certification program for eating disorder coaches. She added that therapists don’t have enough time to help with real-world exposures. CCI-trained coaches can provide regular check-ins, ongoing text support, or even temporarily live with their clients to accompany them in challenging moments, such as eating a bagel with cream cheese or shopping for clothes in a larger size.
CCI-certified coaches don’t replace licensed professionals but work alongside them, helping clients meet goals set by their therapists or dietitians. In an online post, Costin states that coaches are trained to help clients navigate everyday challenges, while therapists, dieticians, and other professionals focus on identifying and working on the underlying causes of the illness. Through coaches’ real-time support, some clients shared, they can recover from setbacks without waiting for the next therapy session. For someone who feels every meal a battle, who is tempted by compulsive exercise, or who dreads grocery shopping, the thinking goes, that immediate intervention can be critical.
Coaches often report that clients value communicating with someone who has their own experiences with mental health challenges. Because eating disorders carry shame, clients may feel more comfortable sharing their thoughts and behaviors with someone who has been through something similar, rather than with a therapist who, they fear, might judge them. Personal experience may also help coaches pick up on behaviors that others might overlook. For Kevin and Christina Olmsted, a couple in Northern California, helping their then-teenage daughter recover from anorexia was “utter hell and turmoil,” and they believe that hiring a CCI-certified coach — who lived with them for four months and had recovered from an eating disorder herself — was the turning point. “She was like, ‘Look, I’m not here to beat you up or berate you or treat you. I used to have an eating disorder. You can’t bullshit me.’”
While the Olmsteds said they paid $1,000 per day — in addition to providing room and board — coaches may charge less than therapists, which might incentivize some clients to choose them over licensed professionals, depending on their out-of-pocket costs. Costin hopes that insurance will eventually cover coaching, although this would require more research on its efficacy. Alexis Audigier, an independent researcher and CCI-certified coach who used to have McArthur as a client, began gathering data on eating disorder coaching, although she has so far struggled to recruit enough clients willing to participate to produce meaningful results.
Coaching might be even more precarious for people experiencing OCD, in part because strategies that can support eating disorder recovery, such as analyzing and challenging distorted thoughts, can actually undermine their treatment.
OCD involves obsessions — persistent, unwanted thoughts or urges— along with compulsions, which are repetitive behaviors or rigid self-imposed rules. These obsessions and compulsions can focus on almost any topic, from cleaning to religion to symmetry. But unlike with eating disorders, where examining thoughts can sometimes help clients disentangle distortions from reality, with OCD it might feed the cycle of obsessions and compulsions.
“I want data. I want data to see if this is helpful or harmful or neutral. I just don’t know.”
Eating disorders and OCD share features, including intrusive thoughts and repetitive behaviors, and exposure is a component of treatment for each. But the recommended treatments differ. Initial OCD treatment involves structured, gradual exposure to feared situations without using compulsions, often paired with medication, while eating disorder treatment focuses on nutritional rehabilitation and therapy addressing both thoughts and behaviors. Some coaches offer OCD-specific services, but experts are skeptical. Jonathan Abramowitz, an OCD specialist and psychologist at the University of North Carolina – Chapel Hill, told Undark that he believes people with OCD should see one therapist at a time for a particular problem — and any potential coaching should be first discussed with the therapist. “If the coach said, ‘Don’t do A, B, and C,’ and if I’m saying ‘You should do A, B, and C,’ then that puts the patient in the middle,” he said. And that “makes a person who’s already anxious even more anxious and confused.”
OCD therapist Joshua Fletcher isn’t against mental health coaching, but emphasized that in some cases, the dynamic can be exploitative. In an interview with Undark, he described working with people who, in his view, had been manipulated or abused in the context of coaching relationships — an allegation echoed in posts on popular subreddits devoted to OCD treatment. The problem, he noted in a follow-up email, isn’t the field of coaching itself, but people using “the title of coach to establish authority, make false claims, and extract money from vulnerable people.” If something isn’t working, it’s often on the client to make it right, he wrote, so “they keep paying to ‘get it right’”.
Many OCD coaches make bold claims. Danielle Jhiani, an OCD coach who charges $250 for an individual session, promises on her website that her method “has NEVER failed to work for those who learn it and apply it consistently!” The website is full of testimonials, many with stock photos representing satisfied clients. (When asked about the photos, Jhiani said they’re sometimes used for clients who don’t want their real photos shared.) She offers a full refund for cases where her coaching doesn’t work but told Undark that no one has taken her up on it. “I’ve never seen somebody follow the steps that I suggest and it not work for them,” she said.
In explaining the value of coaching, Jhiani wrote in an email that she personally did not get everything she needed to recover from therapy and that she had to learn some things on her own. “Who better to learn from than someone who’s personally overcome OCD and truly understand the ins and outs of the recovery journey?” she asked.
Abramowitz cautions that even the gold standard treatment, exposure and response prevention, doesn’t always work: “I do ERP all the time and it’s a good treatment, but I would never say that it’s never failed. I mean, it fails with people sometimes. That’s just life.”
Both Fletcher and Abramowitz said that people struggling with OCD might benefit from coaching in other aspects of their life — for example, fitness or relationships — but they urge caution when it comes to OCD treatment itself. “If you’re telling a vulnerable person with a complex condition what to do,” Fletcher said, “you’re exploiting them.”
The very qualities that make coaching for eating disorders and OCD attractive — flexibility, accessibility, and relatability — also raise concerns. Unlike therapists, who are subject to state-by-state licensing requirements, coaches are largely unregulated. While this allows people in areas with limited access to specialized treatment to get support, it also means that clients may have little ability to hold a coach accountable in case of harmful or unethical behavior. An inadequate therapist can lose their license; a harmful coach, on the other hand, may simply lose a client. “At some level there’s kind of a ‘buyer beware’ attitude,” said Rebecca Haw Allensworth, a legal scholar studying professional licensing at Vanderbilt University. Allensworth said legal action, such as tort suit or criminal charges, is theoretically possible, but only in extreme cases. Becoming a coach requires no formal qualifications, and clients sometimes spend hundreds of dollars per session for their guidance.
Bulik at UNC warns that when coaches work with individuals who don’t have access to therapists and medical doctors, they’re effectively replacing trained professionals. “I can imagine that they could be worse than nothing,” she said. Online eating disorder coaches can’t weigh their clients and aren’t trained to manage suicidal ideation or treat common comorbidities such as depression, OCD, and anxiety. “I don’t think that without training you can recognize and help manage all of those problems,” Bulik said.
An inadequate therapist can lose their license; a harmful coach, on the other hand, may simply lose a client.
Even when coaches collaborate with a treatment team, confusion and conflict may arise. Bulik emphasized that coaches need boundaries: “Their role needs to be clearly delineated and they have to stay in their lane and not contradict what the dietician, therapist, psychiatrist, PCP [primary care physician] says.”
Conflicting information can be difficult to navigate. One client who has worked with four coaches at different times to help address her eating disorder, recalled being caught in a disagreement between her coach and her dietitian over a meal plan. “I kind of felt stuck in the middle where I was like, ‘Okay, who do I side with?’” she said.
There is also the matter of training: Some coaches have no qualifications beyond their own recovery. Critics say that while personal experience can be valuable, having recovered from an illness doesn’t necessarily mean someone knows how to help others. Some coaches also promote unconventional methods, claiming their clients can achieve recovery within weeks, though experts argue this is unrealistic.
Meredith O’Brien, a licensed therapist and CCI-trained coach, said that recovery takes years. Evidence-based treatment programs take weeks or months; in the United Kingdom, individuals diagnosed with anorexia nervosa are usually offered between 20 and 40 weekly therapy sessions, depending on the treatment type.
A handful of certification programs are currently working to standardize mental health coaching, but they vary in rigor. Costin’s online program is self-paced and must be completed in 18 months, unless participants request and pay for an extension. It involves quizzes and a final exam, as well as 10 hours of client sessions, which students conduct for free and record for Costin to review. Other programs — such as one offered by Dorie McCubbrey’s Eating Disorder Intuitive Therapy — appear to offer basic certification with no supervision, following some home study and a short ungraded test. According to McCubbrey’s website, higher levels of certification involve one-on-one calls with her. (McCubbrey didn’t respond to multiple requests for comment, and Undark was unable to confirm whether the courses are still being offered). Yet, alumni of both programs call themselves “certified coaches.”
Costin says she founded her institute to promote ethical, evidence-based methods. Her training program isn’t independently regulated — although she says she requires her coaches to follow the same standards therapists follow, including adhering to confidentially regulations and using secure messaging platforms — and participation costs $7,200.
Not all coaches opt for certification.
While eating disorders and OCD share many characteristics, experts seem to be more optimistic about the role of coaches in working with the former, provided they’re paired with adequate medical and psychological care. According to CCI’s director of operations Cassie Copperfield, some therapists, dietitians, and medical doctors even refuse to work with eating disorder clients who don’t have a coach. In the case of OCD, on the other hand, full-time support from a coach — depending on how they’re interacting with a client — might fuel the illness by reinforcing compulsive reassurance-seeking.
Mental health coaching faces many challenges, but interviews with clients suggest its presence reflects unmet needs in the mental health system. Access to licensed professionals for eating disorders and OCD is limited by high costs, long waitlists, and insurance denials for those assumed to be not sick enough for care. Many patients complain about outdated treatments and feeling misunderstood by therapists. Coaching aims to fill these gaps.
While licensing may reduce or control unethical practices, Haw Allensworth said, strict regulations can increase costs and limit access without fully eliminating the potential problems. She said that coaches could remain unlicensed as long as they don’t try to offer services reserved for licensed professionals and suggests the focus should be on keeping the coaches “in their own lane,” rather than imposing qualifications.
A handful of certification programs are currently working to standardize mental health coaching, but they vary in rigor. And not all coaches opt for certification.
For people who are seeking a mental health professional, Fletcher, the OCD therapist, warns against red flags: promises of recovery within a specific timeframe, websites featuring testimonials, and lack of supervision and oversight. Other experts point to qualifications and say personal experience isn’t enough. For instance, while Jhiani told Undark that she can teach ERP because she learned it from four therapists during her own recovery, Abramowitz cautioned against equating lived experience with clinical expertise. To skeptics, Jhiani responded: “I’ve learned it. And from four very good therapists. Not only that, though, I’ve personally been through it. So there’s perspectives and knowledge that I have that they don’t have.”
Despite the concerns, at least some coaching clients stress that the service has benefited them. “I’ve been through lots of rounds of treatment,” said McArthur, the client of multiple eating disorder coaches, who has also spent significant time with more traditional treatments. “And I think coaching was probably the most influential, at least at this point in my recovery.”
UPDATE: This piece has been updated to adhere to Undark reporting guidelines.
If you or someone you know needs mental health support in the U.S., the Substance Abuse and Mental Health Services Administration helpline is available by calling 1-800-662-HELP (4357). There is also support available by texting your zip code to 435748 (HELP4U).
Paulina Rowińska is a science writer and the author of “Mapmatics,” an award-winning popular science book on the mathematics of maps. She earned her doctorate in mathematics at Imperial College London and is currently a writing fellow at Quanta Magazine.